Online Mentoring Community Service

Thank you for your interest in becoming a Volunteer Mentor. This application form will give us an understanding of experiences and qualities you have that may make you suitable to be a PIF Mentor for the Pass It Forward Movement.

Full name and Address*	Daytime Telephone:
	Evening Telephone:*
	Email Address:
Work Experience: Name of your PIF Program:
Job title, company's name and address (if currently employed):	Please give details of your employment experience:
Please describe any interests / hobbies / sports / voluntary work you may be involved with which may be helpful in matching you:	Please outline your reasons for wanting to be a PIF Mentor:
How much time are you able to commit as a volunteer Mentor?
Hours per Week: or per Month
Preferred Days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Do you have any special needs which we should know about in order to ensure you have equal access to the Mentoring process, eg Disability access?
You would understand that some people who may benefit from your help as a Mentor may in some way be vulnerable. In recruiting volunteer Mentors, we have an obligation to protect both them and you. For this reason, we ask you to supply two referees; One referee should be from someone that can comment on your employment experience and another referee to comment on your personal qualities. Neither of which can be a member of your family. Please enter their names and contact details in the space provided below so that we can get in touch with them.
Referee 1, your employer. Name, Address and Telephone	Referee 2, personal.* Name, Address and Telephone
Again in the interest of protecting potentially vulnerable people, I should be grateful if you would kindly complete section A or B, below, which covers possible criminal record provision. Please note that a criminal record will not necessarily prevent a person from becoming a Volunteer PIF Mentor.
Declaration (Fill in A OR B)
A) I declare that I do NOT have a criminal record.
B) I declare that I do have a criminal record, of which details are below:
* Denotes a required field